Successful endoscopic management of large upper gastrointestinal perforations following EMR using over-the-scope clipping combined with stenting.

Large iatrogenic gastrointestinal perforations (greater than 15–20mm) following therapeutic endoscopy remain a challenge despite growing expertise in endoscopic perforation closure techniques. Current treatment options include stenting [1,2] or clipping, including the use of an over-the-scope clipping device [3–5]. We present our experience using a combination of over-the-scope clipping and stenting for the treatment of challenging large iatrogenic gastrointestinal perforations. In our first case, a 70-year-old man with a 20-cm-long Barrett esophagus underwent endoscopic mucosal resection (cap suction technique) of a 15-mm early neoplasm situated in the distal esophagus. Following resection, a 20-mm perforation was observed. Under CO2 insufflation, endoscopic closure was attempted using a large 12-mm sharp-tooth OTSC clip (OVESCO Endoscopy AG, Tübingen, Germany), followed by placement of a fully covered stent (●" Video1,●" Fig.1). Contrast fluoroscopy at 1 week demonstrated no signs of leakage nor stent migration. The patient recovered well despite developing pleural effusion needing thoracic drainage and antibiotic therapy. The esophageal stent was removed after 6 weeks and adequate healing of the perforated site was confirmed. In the second case, a 68-year-old man with a 35-mm elevated duodenal lesion underwent successful free-hand piecemeal snare resection. Three days after the procedure the patient presented with localized retroperitoneal soiling. A large duodenal perforation was identified (●" Fig.2) and was initially treated with placement of a fully covered stent fixed to the antrum with several clips to avoid migration. Three days later the stent migrated. After removal of the stent, an OTSC clip was placed along with two other standard clips (under CO2 insufflation) to ensure full-length closure of the perforation. Another fully covered stent was again placed over the perforation, and no fixation was required (●" Fig.3). The patient recovered well with the stent in place. After 8 weeks the stent was removed, revealing a deep scar. Endoscopy_UCTN_Code_TTT_1AO_2AZ